Healthcare Provider Details

I. General information

NPI: 1619959145
Provider Name (Legal Business Name): GREGORY STANLEY ZOLKOWSKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 E SAN MARTIN ST
BOLIVAR MO
65613-2893
US

IV. Provider business mailing address

PO BOX 536
BOLIVAR MO
65613-0536
US

V. Phone/Fax

Practice location:
  • Phone: 417-777-4749
  • Fax: 417-777-8041
Mailing address:
  • Phone: 417-777-4749
  • Fax: 417-777-8041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-11776
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-11776
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number101186
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: